Clinical Simulation and Patient Safety


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  • An exciting prospect of seeing learning in this way is that we can look for CLICK learning in the simulator and CLICK in the theatre, AND we can think about how the two systems might reinforce – or fail to connect with – each other.
    This implies that, (in teaching and in research) as well as trying to structure each separate system to support students’ learning, we should consider how meanings will pass from one to the other, what reconstructions might be required of students (and others!) in that process in order to be responsive to the different characteristics of the systems. Simple notions of learning theory in the simulator and applying it on the ward, or developing a skill in the simulator and using it in the operating theatre are problematised by this approach
    It also provides a way of looking at the problem of transferring learning from the simulator to the real theatre. It alerts us to the fact that is almost bound to be problematic, but that in engaging with the contradictions and disagreements that emerge, opportunities are created for new learning for everyone involved.
  • CLICK FOR TRIANGLE For Engeström, each activity system consists of individual and group actions directed towards something (the object). Each activity system should be considered as a whole, key questions being about the interplay of the different voices, each with its different history, role, dispositions, concerns. The object-oriented actions of the activity system are ‘always, explicitly or implicitly, characterized by ambiguity, surprise, interpretation, sense making, and potential for change’ (Engeström, p134). They are influenced and mediated by the social setting of the activity system.
    You can see some nice issues here for simulation – CLICK what is the object of a session in a simulator (exclusively student learning? – or also research?), what kind of interplay is there between the different voices (of the student, the trainer, the person in role as surgeon etc), how is ambiguity and surprise handled.
    In addition activity theory emphasises that in related activity systems all of this is going on separately in each – CLICK what is the object of a real operation? – where does student learning fit? – what kind of interplay is there between the people including the real surgeon, how is ambiguity and surprise handled? Because the objects, roles, social circumstances vary we would expect there to be difficulties in carrying ideas and actions from one to the other.
    And yet there is transfer. People in related systems jointly construct meanings about objects on their boundary and come to jointly shared understandings about these boundary objects. It is through these boundary objects that meanings can be shared across the systems. Perhaps CLICK technology such as monitors are boundary object, perhaps CLICK a person who has a very similar position in relation to the student in the simulator and the theatre can be a boundary object, perhaps relevant CLICK theoretical understanding can be the bridge.
  • Clinical Simulation and Patient Safety

    1. 1. Clinical Simulation and Patient Safety Paul Bradley Director of Clinical Skills Peninsula College of Medicine and Dentistry Scottish Clinical Skills Network University Campus Hamilton September 27th, 2007
    2. 2.  Patient safety – how big is the problem?  So what does clinical simulation have to offer?  How can we go about this?
    3. 3. Patient safety – how big is the problem?
    4. 4. Why Patient Safety  “To err is human” in the USA  “An organisation with a memory” in the UK Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000 Department of Health. An organisation with a memory. London: Stationery Office; 2000
    5. 5. The size of the problem  400 die/seriously injured in adverse events involving medical devices  ~10,000 people experienced serious adverse reactions to drugs  ~1,150 suicides in people with recent contact with mental health care  ~28,000 written complaints about clinical treatment in hospitals  NHS pays £400 million a year settlement of clinical negligence claims  Potential liability of around £2.4 billion  Hospital acquired infections cost nearly £1 billion.
    6. 6. The size of the problem  850,000 adverse events in the UK per year  10% of all hospital admissions  In the USA estimated 44,000 – 90,000 deaths per year – that’s equivalent to 15-30 September 11th s  1 million extra hospital days in USA  12.9% of all hospital admissions in NZ
    7. 7. 5th NPSA Report - 2005  Analysis of the 1,804 serious incidents resulting in death.  Reducing to 576 deaths that could be interpreted as potentially avoidable and related to patient safety issues.  425 occurred in acute/general hospitals.  71 related to a range of diagnostic errors  64 related to patient unrecognised deterioration  43 involved a problem with resuscitation after cardiac arrest. National Patient Safety Agency. The fifth report from the Patient Safety Observatory - Safer care for the acutely ill patient: learning from serious incidents. London; 2007.
    8. 8. Recommendations - deterioration  Better recognition of patients at risk of, or who have deteriorated  Appropriate monitoring of vital signs  Accurate interpretation of clinical findings  Calling for help early and ensuring it arrives  Training and skills development  Ensuring appropriate drugs and equipment are available
    9. 9. Recommendation - resuscitation  Improving communication  Better situation analysis  Regularly risk assessing resuscitation processes locally  Training and skills development  Ensuring appropriate equipment is available
    10. 10. “These are not new concerns and, in spite of much high quality work over many years, still more energy and commitment towards improvement is needed.”
    11. 11. It isn’t history 26: Emergency support in surgical units: Dealing with haemorrhage Issued: 10 Sep 2007 Following the death of a patient, the National Patient Safety Agency is warning that surgery should not be commissioned or delivered in facilities which lack the systems and equipment to manage emergencies safely. In a recent incident a patient died following routine laparoscopic surgery exacerbated by no blood being available, a lack of critical resuscitation devices such as central venous catheters and an absence of surgical equipment such as abdominal packs and vascular sutures.
    12. 12. So what does clinical simulation have to offer?
    13. 13. Simulation “The technique of imitating the behaviour of some situation or process (whether economic, military, mechanical, etc.) by means of a suitably analogous situation or apparatus, especially for the purpose of study or personnel training.” The Oxford English Dictionary – Online 2006
    14. 14. Simulation in medical education – is not new
    15. 15. Too dangerous  Chess – 6th Century  War games  Weapons simulations
    16. 16. Too costly  Space exploration  Mission training
    17. 17. Too important  Civil and military aviation  Nuclear power industry
    18. 18. Simulation in skills education Part task trainers Simulated patients and role plays Hi- and intermediate fidelity simulation Haptic/VR simulators
    19. 19. 1950 1960 1970 1980 1990 2000 Resuscitation movement The movements in modern medical simulation
    20. 20. 1950 1960 1970 1980 1990 2000 The movements promoting modern medical simulation Åsmund Lærdal Resuscitation movement Resuscitation movement
    21. 21. 1950 1960 1970 1980 1990 2000 The movements promoting modern medical simulation Stephen Abrahamson Sim One
    22. 22. Sim-One “It breathes; has a heart beat, temporal and carotid pulse (all synchronized), and blood pressure; opens and closes its mouth; blinks its eyes; and responds to four intravenously administered drugs and two gases (oxygen and nitrous oxide) administered through mask or tube. The physiologic responses to what is done to him are in real time and occur ‘‘automatically’’ as part of a computer program.” Abrahamson S, Denson JS, Wolf RM. Effectiveness of a simulator in training anesthesiology residents. Qual Saf Health Care 2004;13(5):395-397.
    23. 23. 1950 1960 1970 1980 1990 2000 The movements promoting modern medical simulation CASE (Comprehensive Anesthesia Simulation Environment) - Stanford GAS (Gainesville Anesthesia Simulator) Florida Patient simulator
    24. 24. 1950 1960 1970 1980 1990 2000 The movements promoting modern medical simulation Patient simulator
    25. 25. Features of modern simulators  Complete human body  Capable of “speech”  Complete integrated physiology/pharmacology model (high fidelity)  Open/close mouth  Trismus  Realistic airway  Pharyngeal oedema  Respiratory chest (± abdominal wall) movements  Appropriate anatomical landmarks  Lungs capable of spontaneous, assisted or mechanical ventilation  ± consumption of O2, exhalation of CO2 and uptake of anaesthetic gases  Tongue swelling  Difficult airways  Synchronised breath sounds  Bowel sounds
    26. 26. Features of modern simulators  Monitoring  Pulses palpable  Synchronised with heart sounds  Blood pressure measurable  Variety of physiological outputs to standard monitors e.g.  CVP  Temperature  Pulse oximetry  Procedures  Defibrillation  Pneumothorax decompression  Cardioversion  Cricothyroidotomy  External pacing  Pericardiocentesis  Venepuncture  Chest drain insertion  Cannulation  Intramuscular injection  Urinary catheterisation
    27. 27. 1950 1960 1970 1980 1990 2000 The movements promoting modern medical simulation 40.2 Skills objectives a) basic clinical method i. obtain and record a comprehensive history ii. perform a complete examination and assess mental state iii. interpret the findings obtained from the history and examination iv. reach a provisional assessment of patients’ problems and formulate with them plans for investigation and management b) basic clinical procedures including i. Basic and Advanced Life Support ii. venepuncture iii. insertion of an intravenous line Medical education reform
    28. 28. 1950 1960 1970 1980 1990 2000 Resuscitation movement Medical education reform Sim-One The movements promoting modern medical simulation Patient simulator
    29. 29. Cummulative growth in "simulation" publications 0 100 200 300 400 500 600 1963 1968 1973 1978 1983 1988 1993 1998 2003 Source: Boston Simulation Centre
    30. 30. BEME systematic review  Providing feedback  Allowing repetitive practice  Integrating within curriculum  Providing a range of difficulties  Being adaptable; allowing multiple learning strategies  Providing a range of clinical scenarios  Provides safe, supportive learning environment  Active learning based on individualized needs  Defined outcomes  Simulator validity as a realistic recreation of complex clinical situations Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher 2005;27(1):10-28.
    31. 31. The benefits of simulation  Risks to patients and learners are avoided  Undesired interference is reduced  Tasks/scenarios can be created to demand  Skills can be practised repeatedly  Training can be tailored to individuals  Retention and accuracy are increased  Transfer of training from classroom to real situation is enhanced  Standards against which to evaluate student performance and diagnose educational needs are enhanced Maran NJ, Glavin RJ. Low- to high-fidelity simulation - a continuum of medical education? Medical Education 2003;37(s1):22-28
    32. 32. Potential application of simulation  Routine learning and rehearsal of clinical and communication skills at all levels  Routine basic training of individuals and teams  Practise of complex clinical situations  Training of teams in crisis resource management  Rehearsal of serious and/or rare events  Rehearsal of planned, novel or infrequent interventions  Induction into new clinical environments and use of equipment  Design and testing of new clinical equipment  Performance assessment of staff at all levels  Refresher training of staff at all levels
    33. 33. Responsibilities for patient safety Organisation Institution Individual Team Patient safety …and the place for clinical simulation Patient safety Institution IndividualTeam
    34. 34. How can we go about this?
    35. 35. Building on theories of learning  Medical education and clinical skills learning is a theory rich educational environment Behaviourism Constructivism Social constructivism Reflective practice Situated learning Activity theory Bradley, P., & Postlethwaite, K. (2003). Simulation in clinical learning. Medical Education, 37(s1), 1-5.
    36. 36. Learning theories  Theories can inform our practise  Models of teaching and learning can be developed that best support our students  Theories can be tested  Theories can be revised
    37. 37. Activity theory
    38. 38. From Engeström Y 2001 Expansive learning at work: toward an activity theoretical reconceptualization. Journal of Education and Work 14,2,133-156 Simulator Work in operating theatre Object 1 Rules Community Division of labour Subject Mediating artifacts Object 1 CommunityDivision of labour Subject Mediating artifacts Rules Object 2 Object 2 Object 3 Activity Theory
    39. 39. Aha Aha
    40. 40. Research  Evidence to date has been weak and patchy  Much published work is descriptive or at low level of evaluation  Despite this simulation has certainly established itself as a major educational movement  We cannot always wait for the results of empirical research to address major issues  Sound, robust research is still needed to address key areas
    41. 41. A possible way forward  Use multiple methods approaches  Encompass the interpretive paradigm  Make more targeted use of the scientific paradigm to capitalise upon its particular ‘range of convenience’  Strive for increased theoretical clarity with respect to learning theories  Together, these ideas could lead to rather different kinds of enquiry
    42. 42. Conclusions  Clinical simulation can enable learning of institutions, individuals & teams  It can play an important part in addressing issues of patient safety  Has a role at all levels of seniority within and between professional groups  It exists as a spectrum of educational activities - it is not a dichotomy of low and high fidelity, but a continuum  Not just technological/computerised – include important human interactions - may be one-to-one or within or between teams  Clinical simulation can test and challenge systems, policies and plans  Evidence to date tends to be of a low level evaluative nature, to be weak in methodology and to be of limited generalisability  Robust research focussed on higher level outcomes is required
    43. 43.
    44. 44. Responsibilities for patient safety Organisation Institution Individual Team Patient safety
    45. 45. …and the place for clinical simulation Patient safety Institution IndividualTeam
    46. 46. …and the place for clinical simulation Patient safety Institution IndividualTeam
    47. 47. Simulators